1/29/2014

APPLICATION FORM FOR LICENCE TO DRIVE A MOTOR VEHICLE

APPLICATION FORM FOR Licence TO DRIVE A MOTOR VEHICLE FORM - 4 (See rule - 14)
To The Licencing Authority,

I enclosed Learners Licence No appropriate box)

Dt.

Issued by L.A

I hereby apply for a Licence authorising me to drive the following vehicles ( Tick at the

A) B) C) D) E) F) G)

Motor cycle below 50cc Motor cycle above 50cc Light Motor Vehicle (includes Cars & Jeeps) Transport Vehicle Road Roller Invalid Carriage (incase of physically handicapped applicants) Any Other Category (Specify the category in the box)

(Please fill the following particulars in CAPITAL Letters only)

1. FULL NAME (Leave one Space between first and last name) 2. Son/Daughter/Wife of

3. SEX 4. ADDRESS Door No. Village/town/city Mandal District Pincode 5. DATE OF BIRTH

MALE PERMANENT

FEMALE TEMPORARY

6. EDUCATIONAL QUALIFICATION 7.IDENTIFICATION MARKS

1 2

8. (Optional) : BLOOD GROUP & Rh FACTOR

http://www.aptransport.org/html/form4.php

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1/29/2014

APPLICATION FORM FOR LICENCE TO DRIVE A MOTOR VEHICLE

Disclaimer : The applicant is solely responsible for any medical complications that may arise due to wrong declaration of the Blood group. 9. Particulars and date of every conviction which has been ordered to be endorsed on any Licence held by the applicant. 10. Particulars of disqualification of the applicant from obtaining a Licence to drive,and reasons for it.

Applicant's declaration

12. I enclose the Driving Certificate No. Issued by 13. 14. 15. 16.

Dated

I have submitted along with my application for learner's Licence the written Yes consent of parent/guardian I have submitted along with the application for learner's Licence/I enclose the medical fitness certificate I am exempted from the medical test under Rule 6 of the Central Motor Vehicle Rules 1989 I am exempted from primary test under rule 11(2) of the Central Motor Vehicle Rules 1989 Yes Yes Yes

No No No No No

I hereby declare that to the best of my knowledge and belief the particulars Yes given above are true. Note:Strike out whichever is inapplicable.

Signature/Thumb Impression of applicant.

CERTIFICATE OF TEST OF COMPETENCE

The applicant has passed the test prescribed under rule 15 of the CMV rules, 1989. The test was conducted on vehicle with Reg.No. on

The applicant has passed the test prescribed under rule 15 of the CMV rules, 1989. Result of the Test: Absent If failed Reasons for failure
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Passed

Failed

1/29/2014

APPLICATION FORM FOR LICENCE TO DRIVE A MOTOR VEHICLE

Name of Testing Autority Code Signature of the Testing Authority Submit

http://www.aptransport.org/html/form4.php

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